Test 1 NUR 151

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1.

CCHINS

caring, critical thinking, holism, information

management & technology, nursing role
development, safe practice

2.

nursing is...

assisting individuals families, and communities

in attaining, maintaining, and recovering
optimal health. Nursing treats the human
response - is not medicine.

3.

florence
nightingale

began the formalized role of nursing with

training and schooling.

4.

nightingale's
theory

therapeutic environment, empathetic care,

confidential care, care through vital
assessment, care that encourages
independence and restoration of health

5.

Linda
Richards

Americas first trained nurse - created the

charting system and a nurse training school at
Boston College Hospital.

6.

Clara Barton

Founder of Red Cross

7.

Mary
Breckinridge

Nurse midwife - frontier nursing service

8.

Dorothea Dix

Superintendant of nurses in union army reformed mental health nursing

9.

Mary
Elizabeth
Mahoney

first professionally trained black female nurse

10.

Lilian Wald

founded Henry Street Settlement - worked in

community health nursing

11.

CANDO
program

nurses who are chemically addicted and in

treatment can keep license if approved to
participate in this program

12.

AZBN

arizona state board of nursing - enforces the

Nurse Practice Acts to hold standards to the
nursing care and protect the public, they issue
and renew and revoke licenses

20.

Advance
directives

right to change mind at any time - DNR - do

not resuscitate, Living will - document w/
specifics of what pt desires for pt care,
Power of attorney for healthcare - a person
chosen whom knows what you would like
done medically and will enforce that.

21.

Negligence

failure to perform as a reasonable, prudent

nurse would, failure to follow standards of
practice, no intent to harm is present

22.

Malpractice

professional form of negligence. For one to

collect - must existence of duty, breach of
the duty, causation, and damages

23.

Assault/Battery

assault - threat or attempt to make bodily

contact with someone without consent.
Battery is an assault that is carried out

24.

Palliative care

relieve uncomfortable, provides pain relief

and comfort measures but does not try to
prolong the person's life

25.

Hospice care

treatment of the terminally ill with the goal of

helping them to die comfortably, without pain

26.

Bereavement
care

Support services to friends and family after

the patient's death for up to one year

27.

Respite Care

a service that provides short-term relief or

time off for persons providing home care to
an ill, disabled, or frail older adult

28.

HEENT

head, ears, eyes, nose, throat

29.

AROM/PROM

active range of motion, passive range of

motion

30.

JVD

jugular vein distention - may indicate heart

problems. pt sitting up at 30-45 degree angle
and check for JVD

31.

PERRLA

Pupils Equal Round Reactive to Light and

Accommodate (distance)

13.

NCSBN

national council State Boards of Nursing develops the NCLEX and regulate uniformity of
nursing practice

32.

20/20

top number is how far away you are/ bottom

is how far a perfect sighted person would be
to see it

14.

ANA

american nursing association - assisting

nurses to unite and address issues that
nurses deal with

33.

Visual Field

area observable with the eye, cranial nerves

3,4,6 are responsible

34.

Whisper test

15.

EMTALA

emergency medical treatment... ensures that

medical treatment is given to a pt that does
not have insurance or money

stand 1-2 feet behind & whisper random

sentence while they cover one ear, repeat
with other ear

35.

Watch test

16.

ADA

americans with disabilities act - pt and medical

staff do not have to disclose HIV/AIDS status

5 inches away from ear & can still hear

second hand

36.

Halitosis

bad breath

17.

Patient selfdetermination
act

we must provide pt with all options available

37.

Thrush

possible causes; chemo, bad oral care,

antibiotics

18.

The Bill of
Rights

10 amendments apply to nursing practice for

patients and nurses

38.

Subjective
Data

what the pt says - not measurable

19.

HIPAA

protecting patients rights and privacy

39.

Objective Data

observable data that can be measured what you smell, touch, hear, see

40.

Comprehensive

interview, head to toe, admission to new

facility

41.

Focused

abbreviated focused on one body part or

illness

42.

Ongoing
treatment is...

as needed, with each patient interaction

43.

Emergency

trauma, rapid, critical times

44.

Body System
Approach

head to toe same every time - inspection,

palpation, percussion, auscultation. except
for GI palpate after auscultate

45.

CNS

central nervous system - made up of the

brain and spinal cord - fight, speeds
heartbeat

46.

PNS

peripheral nervous system - made of spinal

nerves, many cranial nerves and autonomic
nervous system - flight, slows heartbeat

47.

PMH

past medical history

48.

LOC

level of consciousness AVPU alert, verbal stimuli, painful stimuli,

unresponsive

49.

Neuro
Assessment

cerebral, cranial nerves, motor, sensory,

cerebellar, reflexes

50.

Vital Signs

temperature, pulse, respirations, blood

pressure, pain, sometimes blood sugar and
pulse ox are included

51.

Rectal
Temperature

most accurate, red thermometer - but most

invasive and uncomfortable.
37.5C = 99.5F

52.

Oral and
Tympanic
Temperature

convenient, safe but not as accurate

37C = 98.6F

53.

Pulse

HB normal range 60-100bpm

54.

Tachycardia

rapid hr, above 100bpm

55.

Bradycardia

slow hr, below 60bpm

56.

Pulse Volume

0=absent
1=thready/weak
2=weak
3=normal
4=bounding/full

57.

58.

Pulse Sites

Respirations

radial
pedal
post tib
politeal
femoral
brachial
carotid
temporal

59.

Abnormal
Breathing

apnea=stop
tachypnea=fast
bradypnea=slow
dyspnea=difficult
orthopnea=difficult in position

60.

Pulse ox

SpO2
normal 90%-100%

61.

Blood
Pressure

below<90/60 is hypotension
90-120/60-80 is normal
120-140/80-90 is pre-hypertension
above>140/90 is hypertension
if needed to repeat, wait 2 minutes between

62.

K sounds are

Korotkoff's sounds=the sounds you identify

while taking BP

63.

GCS

neuro assessment 3-15

eye opening 1-4
verbal response 1-5
motor response 1-6

64.

GCS eye
opening

alert=4
verbal=3
pain=2
unresponsive=1

65.

GCS verbal
response

oriented=5
confused=4
inappropriate=3
incomprehensible=2
none=1

66.

GCS motor
response

obeys commands=6
localises to pain=5
withdraws from pain=4
flexion to pain=3
extension to pain=2
none=1

67.

Cranial
Nerves
Mnemonic

Oh Oh Oh To Touch And Feel Very Good

Vibes AHh
Olfactory, Optic, Oculomotor, Trochlear,
Trigeminal, Abducens, Facial, Auditory,
Glossopharyngeal, Vagus, Accessory,
Hypoglossal

68.

Cranial Nerve
Duties
Mnemonic

Some Say Marry Money But My Brother Says

Big Boobs Matter More

69.

Proprioception

where you are in space

70.

Eccymosis

leakage (extravasation) of blood into the skin

or mucous membrane- purple but not a bruise

71.

Petechiae

small hemorrhagic spots of capillary bleeding

common with thrombocytopenia

72.

Clubbing

reduced oxygen levels, common with lung

cancer, cystic fibrosis, celiac disease,
cirrhosis and other liver diseases, dysentery,
graves disease, overactive thyroid,

73.

abnormal
nails

white spots - zinc deficiency

spoon shaped nails - iron deficiency
splinter hemorrhage - injury to brittle nail

average is 12-20 per minute

breathing out takes longer than in normally

74.

Tissue Paper
My Assets

blood route Tricuspid, Pulmonic, Mitral,

Aortic

75.

SOB

Shortness of breath

76.

HTN

Hypertension

77.

APE To Man

Aortic ICS2, R
Pulmonic ICS2, L
Erb's Point ICS3, L
Tricuspid ICS5, L
Mitral ICS5 LMCL

78.

Crepitus

subcutaneous air like rice crispies in chest

in joints it feels like grating or grinding

79.

Kussmaul

Labored breathing - metabolic acidosis,

diabetic acidosis

80.

Biot

abnormal breathing patterns, short, long

short...

81.

Cheyne Stokes
respirations

rhythm of abnormal breathing that starts

longer and decreases almost to apnea

82.

Kyphosis

with age reduced lung capacity - hunch

back

83.

COPD

causes Barrel chest

84.

Pleural friction
rub

painful, inflammation

85.

Stridor

upper airway closing

86.

Rhonchi

Partially blocking airway

87.

Lordosis

exaggerated lumbar curve

88.

Source oriented
documentation

each discipline records findings separately easy to find info, but data is scattered

89.

Problem
oriented
documentation

organized around patient problems, allows

collaboration, but required cooperation

90.

CBE

Charting by exception - only significant

findings, saves time, but inadvertent
omissions

91.

Nurses Notes

Narrative, PIE, SOAP, Focus, FACT

92.

PIE

Problem, Interventions, Evaluation - only

used in problem oriented charting, ongoing
plan of care

93.

SOAP/SOAPIER

Subjective, Objective, Assessment, Plan,

Intervention, Evaluation, Revision. Both
source & Problem oriented documentation
use it - inefficient and repetitive

94.

DAR

Data, Action, Response - found in column 3

in focus charting

95.

FACT Charting

Flow Sheets, Assessment with baseline

data, Concise progress notes, Timely
entries

96.

Admission
Database

record of baseline data, chief complain or

reason for admission, physical assessment,
vital signs, allergy, current meds, ADL,

97.

Flowsheets
& Graphic
records

see a flow or vital signs, I&O, allows to see

patterns

98.

MAR

Medication Administration Record - list of

allergies, medications ordered and
documentation PRN, STAT or omitted doses

99.

Progress
Notes

Assessments before & after medications,

information reported to/from provider, important
data collected during treatment

100.

Kardex or
pt care
summary

demo data, medical diagnoses, allergies,

diet/activity orders, safety precautions, ordered
tests/treatments

101.

Care Plans

nurses actions specified as to map out

problems, outcomes, interventions, treatments,
evaluations

102.

D/C
summary

last entry in paper chart, completed when pt

transferred to another unit, facility or d/c home

103.

SBAR

Situation - what is happening now

Background - what led to this situation
Assessment - what do I think problem is
Recommendation - what should we do to fix it